Corruption or unfair perception?
Newspaper headlines and TV news investigations are highlighting some embarrassing abuses and fraudulent acts by a handful of home care companies. And the government has announced that it will crack down on the growing industry.
If one didn’t know better, one might think most home care providers are bilking the government for services they didn’t perform.
Some say this perception is unfair.
"It’s unfortunate that they have focused so much attention on expenditures that are less than 5% of the budget for 1996," says Karen Wade, RN, MS, director of home care services for St. Margaret Mercy Home Care of Hammond, IN.
Elizabeth Hogue, a Burtonsville, MD, attorney, who specializes in health law, says the home care industry has been stigmatized by the fraudulent actions of a few high-profile providers.
Also, she adds, "They seem fixated on the enormous growth of the home care industry over the last few years. I’ve said, What do you expect when people have left the hospital sooner?’ "
Chris Anderson, vice president of compliance and quality improvement for Housecall Medical Resources of Atlanta, says he wasn’t surprised by the recent crackdown.
"Home care has historically been a high growth industry, and within the past decade, it has sustained a higher growth rate than any other industry in health," Anderson says. "Whenever that happens, there’s a natural tendency to scrutinize to make sure it’s a good type of growth, and there have been some companies within the industry that were not ethical providers."
The intense scrutiny on home care follows reports about fraud and abuse put out by the U.S. Department of Health and Human Service’s Office of Inspector General and the Health Care Financing Administration (HCFA), both in Washington, DC.
In a Federal Register report, dated Aug. 10, 1995, the Department of Health and Human Services gave four main reasons "home health care is particularly susceptible to fraud and abuse." These are:
• Medicare covers an unlimited number of visits per patient.
• Beneficiaries pay no co-payments on medical equipment.
• Patients don’t receive explanations of benefits for bills submitted for home health services.
• There is limited direct medical supervision of home health services provided by non-medical personnel.
The same report found some excessive examples of fraud, including the following:
• a home health agency that billed Medicare for 123 home health visits to a patient who never received a single visit;
• an agency that provided a home health aide to a beneficiary who was able to leave the home at will and even served as a volunteer for a local hospital several times a week.
• an agency that claimed about $26 million in visits for one year, and these were all visits that were never made or were visits to patients that were not homebound or were visits that were not authorized by a physician.
As a result of those earlier investigations, the OIG conducted a demonstration project called Operation Restore Trust (ORT) in five states in 1995. Home health agencies, nursing homes, and durable medical equipment suppliers were investigated for fraud, waste, and abuse of Medicare and Medicaid.
Federal officials said they identified $188 million owed to the government by companies that abused and defrauded the system. As a result of the investigation, more than 200 fraudulent health care providers were excluded from Medicare and Medicaid.
Now ORT is being expanded to 12 more states and eventually to the entire country. So any agency at any time could find FBI agents or Medicare investigators pounding on the door, experts say.
"I think all home care providers are very vulnerable right now," Hogue says.
"I think ultimately the storm will be over, but I think right now they all need to be on their guard," Hogue adds. "And I cannot emphasize enough how important it is for agencies to have a compliance plan and implement it with training for staff."
[Editor’s note: To find out more about the Health Insurance Portability and Accountability Act of 1996, call the American Federation of Home Health Agencies of Silver Spring, MD, at (301) 588-1454. The agency will provide a copy of the act for $4.]
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